I've had a number of parents ask for my advice on
feeding premature babies. Extreme preemies, in particular, are
notoriously difficult to feed; many doctors give up and surgically
insert a G-tube. This can lead to other feeding problems down the road.
(Why learn to eat if a tube automatically brings food to your tummy?
Admittedly, this is much more of a problem for infants who never learned
to eat anything before they were given a G-tube.)

While a G-tube is sometimes necessary in order to
have a healthy baby, it's my opinion that fewer babies would be given
G-tubes if their parents had access to good feeding clinics. Without the
wonderful folks at our feeding clinic, Anastasia would undoubtedly have
a G-tube, too. So if your baby is having trouble eating, I highly
recommend asking your pediatrician, neonatologist, or NICU nurses about
a feeding clinic. If they have no recommendations, try calling nearby
medical universities or children's hospitals, asking for professionals
who specialize in eating difficulties.

That said, some parents have found success in copying
some of the things we've done to combat Anastasia's eating issues.
Although feeding problems should be treated individually, and I am by no
means an expert on the subject, it's my hope that here you'll find one
or two tips that are useful for your own situation.

First, a little background. In the NICU, Anastasia only took some
of her feedings with a bottle; her NG (feeding) tube mostly remained in
place until the day before she left the hospital. For bottle feedings
(breast milk only), we used a Dr. Brown's with a standard Dr. Brown's
nipple. When we brought Anastasia home, she cried and cried and cried
(which is so not her personality!) and writhed as if she was in
pain. We tried giving her over the counter gas drops, but this rarely
helped. The medical people we spoke with weren't overly concerned about
these symptoms, thinking she "just" had colic.

While Anastasia was in the NICU, she was also overfed - although with
good reason. The neonatologists were trying to get her lungs to grow and
improve. When she got home and no longer had her NG tube, she starting
loosing weight. This freaked out her pediatrician, who began mentioning
the possibility of a G-tube. My reply was: "But it seems to me there
must be other things we can try before we go to the extreme of surgery!"
Finally, she referred us to a feeding clinic.

Here's what worked for us:

* Changing nipples.The feeding clinic gave
us a Similac "premature nipple" to use with the Dr. Brown bottle. It
requires no real sucking; the milk just drips out. It made a huge
difference, and I was shocked the NICU never offered us one. The nipple
not only improved Anastasia's calorie intake, but it greatly reduced her
stomach cramps. Apparently she was sucking as hard as she could on the
regular nipple, but wasn't able to get much milk. This made her stomach
cramp up, which made her too uncomfortable to eat. Until 18 months
chronological age, Anastasia used the preemie nipple.

I've searched unsuccessfully for a place to buy these
nipples, but a feeding clinic or hospital will usually give them away,
or sell them for a small fee. I've also seen them new on
eBay. Be sure to get a good supply,
as they rather quickly become too soft and must be replaced.

* Cutting fenugreek. I'd been using the
herb fenugreek in order to boost my milk supply. On the advice of
another mom, I stopped taking it. Within two days, Anastasia's tummy was
more comfortable. To be sure the fenugreek was really the problem, I
went back on the herb. Sure enough, Anastasia started having bad tummy
aches again. I never took fenugreek again.

* Cutting dairy.I
stopped eating all dairy and, combined with the two items above, this
completely rid Anastasia of her tummy aches.

* Formula. My milk supply could no longer
keep up with Anastasia, so I began exploring formulas. On the advice of
other preemie parents, I was going to use
Neocate,
but the feeding clinic folks suggesting trying other, cheaper, formulas
first. Since Anastasia apparently had a problem with dairy, I thought
about offering her a soy formula - but the possible side effects of
soy
formulas disturbs me, so I tried
Enfamil's Gentlease. This is a dairy product, but with reduced
lactose and broken down milk protein. Anastasia did very well on it. (My
son, who was born full term but had trouble with tummy aches, also used
Gentlease. We also found that
Target's version of this formula worked just as well for my son, and
at considerable savings.)

A tip from the clinic: If you supplement with
formula, be sure every feeding has about the same mix of breast milk and
formula. Don't offer breast milk one feeding, formula the next, as this
can upset little tummies.

* Hind milk. Beginning when Anastasia was
still in the NICU, she was given only hind milk. She put on
weight like mad. Hind milk is the latter and fattiest part of
breast milk; I got it by pumping for five minutes and then switching
bottles. The milk from the second set of bottles was all we used.

* Peace...Or Distraction? Anastasia is
easily distracted while she's eating - a common preemie problem. So when
she was little, I took her into the nursery, turned off the light (or
used a very dim light), closed the curtains, turned off the radio, made
sure the TV wasn't going, and shooed everyone out of the room. Rocking
also really helped Anastasia - probably because it made her a little
sleepy.

Other parents of preemies say that distraction is the
only thing that works. One friend bemoaned that the only way to get her
baby to eat was to place him in front of the television. Whatever works!

* Sleepiness. Like most preemies, originally
Anastasia's biggest problem was that she fell asleep before finishing a
feed. We implemented all the usual tricks of tickling, changing
positions, burping frequently, etc. to keep her awake. However, we found
that Anastasia always bottle fed better if she was a little sleepy.
That's true to this day. So we always fed her after a nap,
instead of before a nap. That way, she went into "auto pilot," and was
less likely to get distracted.

* Burping. Once Anastasia got past the
stage where burps were hard to get out (about four months, corrected
age), I found that I should never interrupt her feedings for a burp. If
she really needed one, she'd stop eating on her own, but if I
interrupted her, it was always difficult to get her back to eating.

* Start solids early.
The clinic encouraged us to begin solids at about four months corrected
age (six months chronological). Like most children who are starting
solids, Anastasia mostly just tasted, but I'm sure she also got some
extra calories. There was some disagreement within the clinic about
whether we should start solids this early, but ultimately the doctor
said we should use our own judgment. "Don't push, take plenty of time.
If she doesn't seem ready, stop and try again a few weeks later. If she
takes to it, use the typical precautions of trying one food every three
days or so, in case food allergies appear." See more about solids
below.

* Don't use baby foods. I was shocked to
learn that bottled baby foods (especially veggies) are full of water.
Table food is a lot more nutritious, tastes better, and has more
calories. You don't have to put table food in the blender, either. Just
cook the food thoroughly (steaming veggies helps them retain their
nutrients), mash well with a fork, and spoon into ice cube trays. Once
the veggies are frozen, transfer them to a freezer bag. When you want to
feed the baby, just nuke one of the cubes. (Or feed the baby whatever
veggies are on your plate.)

I found that adding formula to everything made
Anastasia more accepting of new foods. (But don't make the same mistake
I did and add formula to things like peas or corn. This creates a liquid
with lumps, which little ones tend to gag on.)

The clinic did not recommend rice cereal, as
it's not very tasty or nutritious, and tends to cause constipation (an
issue for many preemies). I offered Anastasia baby oatmeal, which she
loved, but the clinic has since informed me that adult oatmeal has a lot
more fiber in it. (Baby oatmeal has the least amount of fiber, adult
"quick cooking" oatmeal is in the middle, and old fashioned oatmeal has
the most fiber. If you use the latter, make sure you cook it extremely
well. If your baby isn't on formula and doesn't get supplemental iron,
use baby oatmeal, anyway, as it contains the iron your baby needs.)

* Reflux medicine. Anastasia was on reflux
medication in the NICU, but was taken off the stuff just before coming
home because the doctor on call didn't believe in them. It took a while
to get her pediatrician to prescribe something - and then several more
weeks to find the right medication for Anastasia. She took Zantac in the
hospital, through an NG tube, but wouldn't tolerate it directly in her
mouth. We ended up using specially flavored Prilosec. Getting
Anastasia's reflux under control really helped her eating, too. Later,
because it was cheaper (given our perscription insurance), we switched
to Prevacid. (For more information about preemie reflux, visit
Infant
Reflux.)

* Adding calories to formula. I know a lot
of parents of preemies add oils and powders to their baby's formula, but
the clinic just had us "soup up" Anastasia's formula by adding a little
extra formula powder. This is not something you should try on your own,
but mention it to your baby's doctor, and see if he or she will approve.
(We used 5 oz. of water to 3 scoops of formula to make a 24 calorie
drink.)

At one point, we did add Polycose (a powder that's
almost all carbohydrates) to Anastasia's formula to increase the
calories. Unfortunately, she did what a smallish number of babies
do...She started eating less.

* Formula Before Solids.
Although many doctors recommend offering solids to the baby before
giving her the bottle, for several months, we found the opposite worked
best for Anastasia (who was still getting most of her nutrition from
formula). We gave her as much formula as she'd take first, and then
offer as many solids as she'll take.

* Cup and Dropper.
On our very first feeding clinic visit, we were given a dropper and a
special cup, which you can see Anastasia using here:

At first, neither were very useful; Anastasia would
just spit out whatever we managed to get into her mouth. However, at
about 8 months corrected age, I tried the cup again. Anastasia was
taking an ounce or two from her bottle, then refusing to suck any more.
So, I took her to the high chair and offered her formula from the pink
cup. She loved the newness of it, I think, and got quite a lot from the
cup. (It is messy and slow going, I must admit. But it gets those
extra calories down!)

If you can't buy this cup, you could use a small
paper cup, and cut an indention in it, like Anastasia's pink cup. This
allows you to easily see how much milk the baby is getting in his or her
mouth. A small clear cup might work, too.

The feeding clinic suggested I put the cup to her
lips and let her lap up milk, but I've found it works best if I get a
little milk in her mouth and then take the cup away and allow her to
swallow.

Older Babies

* Encourage fattening foods.
Once Anastasia was eating oatmeal well, we began offering fattening
foods like avocado and cottage cheese. Don't give up after
one or two tries. If your baby doesn't like the food right away, offer
it at least once every two weeks, and chances are, she'll eventually
take to it. (A trick: In the early days, I could slip almost anything
into Anastasia's oatmeal, and she'd tolerate it so much better than if I
offered it to her by itself. So take a food your baby loves and mix in
just a little of something she doesn't. Gradually add more and more of
the new food.)

* Variety. Anastasia
likes variety, so I always offered at least three different solids per
meal. I might start out with avocado, for example, and feed her that
until she eats it all or doesn't want any more, and then move on to
YoBaby. I always ended each meal with something she could easily feed
herself, like Ritz crackers or Cheetos.

Any time I get stuck in a rut with regard to what
foods I offer Anastasia, she begins eating less.

* Sometimes Bottle, Sometimes
Solids. When Anastasia was about 9 months corrected age, we
completely changed her feedings. (When the feeding clinic suggested this
plan, I was skeptical...but it really worked.) They wanted me to
give Anastasia three bottles a day and three solid-food meals a day,
alternating. (Example: First meal, bottle; second meal, solids; third
meal, bottle; fourth meal, solids.) Because I knew Anastasia took
much more from her bottle when she's sleepy, I changed this a bit
and started giving her a bottle in the morning, solids for her next
three meals, and a bottle in the evening, and another in the middle of
the night. Within a few days, Anastasia was eating considerably more in
the way of solids. At 10 1/2 months corrected age, Anastasia was eating
4-5 tablespoons of solids per meal. That was an incredible improvement.
(Please note that it's important to offer something to drink after each
solids meal.)

* Self Feeding. If your
baby shows an interest in feeding herself, it's important to let her. I
can't count the number of times Anastasia wanted to feed herself, I
didn't allow it, and she promptly refused to eat anything more.

When you're worried about calories, it's tough to see
food all over the floor...This is why self feeding at the end of
the meal is nice. Also, try to offer at least one food that will tend to
stay on the spoon. For example, avocado sticks to the spoon, even when a
baby turns that spoon upside down and waves it through the air. Things
that stick on fork prongs (like chicken or peaches) are also good
choices. (Be sure to use blunt edged baby forks.)

Sometimes, when I really needed to get food down her
and Anastasia wanted to self feed, but would just end up playing with
her food, I held her hand while I fed her. Other times, offering her an
empty spoon to play with distracted her enough that I could get food
into her.

* Sippy Cup?
Although our pediatrician recommended Anastasia start practicing with a
sippy cup at about 6 months corrected, Anastasia simply didn't have the
sucking ability to use any standard sippy cup. (And I think we tried
them all!) So the feeding clinic gave us an old fashioned baby cup. It
has an indented lid with a hole in it. It isn't spill proof, but it's
not as messy as an adult cup, either. Try it with water (or something
else that's easy to clean up) first. Here's the exact, two handled cup
we use:

(If you want to buy a feeding cup and a baby cup in
the same spot, this company also has cups similar to Anastasia's pink
cup:
http://www.kcup.com/nosey.htm )

Some babies do really well with a cup and straw, too.
To help them learn to suck fluid through the straw, try a cup with soft
sides; squeeze it to push a little bit of fluid into the straw. Chances
are, the baby will understand how to use the straw pretty quickly.

For Everyone

* Relax. When I was uptight about
Anastasia's eating, she didn't eat well. When I learned to relax, enjoy
the process, and stop worrying when she ate less, she started eating a
lot more. (Yes, not stressing out is easier said than done!)
Although it's important to track how many ccs or ounces the baby is
eating, try not to obsess like I used to. Look at the bigger picture:
How has she done overall this week? Is she staying in her growth curve?
(Because Anastasia was "overfed" in the NICU, it took her a little while
to find her natural weight and settle into a growth curve.)

* Humor. Retaining your
sense of humor during feedings will not only help you not be so stressed
and frustrated, but it may help your child eat more. As soon as
Anastasia used to start turning away from her bottle or spoon, I'd find
that if I reacted in a silly fashion (making funny noises, silly faces,
singing high notes, etc.) she'll smile or laugh and then eat a little
more. Perhaps this worked because it kept feedings from becoming a power
struggle. Or perhaps it worked because everyone was more relaxed and
eating becomes less stressful. Or maybe it just distracted the babe.

* Don't push your baby.
There are plenty of times I got extremely frustrated because Anastasia
wouldn't eat. At those times, it's tempting to force the bottle or spoon
in the baby's mouth and somehow make her eat. But not only is it
almost impossible to make a baby eat if she doesn't want to, trying to
force food down her will likely lead to oral aversions. In other words,
pushing your baby will only exacerbate your child's eating problems and
lead to long-term difficulties.

This doesn't mean that when Anastasia turned away
from the nipple that I automatically gave up. Instead, I made sure she
didn't need a burp or a diaper change, then offered her the nipple
again. If she still refused, then we ended the feeding. Patience -
lots of it - is necessary when feeding babies with eating issues.

UPDATE 9/28/09:

Parents magazine has an interesting article on
teaching "Healthy
Eating at Home." Despite the fact this article is geared toward kids
who eat normally, it includes many scientifically backed-up ideas that
can be used for kids who don't eat enough:

* In a study of grown women, those who ate off pretty
plates ate more food. Why not try using plates your kids love (Elmo or
Winnie the Pooh, anyone?) and see if it induces them to eat more, too?

* If your child indicates she's thirsty, don't ask
what she wants to drink. Simply bring her a beverage of your choice and
place it in a very large container. Study after study shows the more
food or drink people are offered, the more they consume. If you give
your child a 20 oz. container, studies indicate she'll drink more than
if you give her a 6 oz. container. (Though, of course, you shouldn't
expect her to drink the full 20 oz!.

* When it comes to foods you really want your child
to eat, pile them on the plate. Don't simply given him the portion you
expect him to eat. By giving your child more than you expect him to eat,
he's more likely to eat more.

* Don't insist your child use utensils. Some experts
believe children get more enjoyment from food if they use their hands to
eat. And for kids with eating issues, more enjoyment usually means more
calories.

* Make up fun names for ordinary foods. In the
Parents article, Dr. Brian Wansink, Ph.D., says "In one experiment I
did, preschoolers ate twice as many vegetables when we called them
things like X-Ray Vision Carrots, Power Peas, Tomato Bursts, and, yes,
Dinosaur Trees." In your household you can do this not just with
vegetables, but with fattening foods, too.

* Dr. Wansink also says he puts two different types
of vegetables on his children's plates. "They seem to respond better
when they feel like they're part of the decision-making process," his
wife says. In your household, try putting at least two types of
fattening foods on your child's plate.

Most are undoubtedly well-meant, but when your child
has feeding issues, you're going to get some interesting comments. Some
people think you must be a bad (or stupid) parent, because the idea that
"babies will eat what they need" has been pounded into people's brains
by baby magazines and books. Others say, "Oh, but she looks great!" As
if to say you shouldn't worry, even though myriad of doctors say you
should. Still others will be shocked that you aren't feeding your baby
only "good foods" like fruits and vegetables; they simply can't imagine
the situation could be serious enough that your primary concern is
calories - no matter where they come from. Some people will balk that
you let your infant watch TV (for example) while he's eating. "The
American Academy of Pediatrics says children under 2 shouldn't watch TV
at all!" they say. True, you reply. But that's the only way you seem to
be able to get those calories down ...

Hang in there and try to find other parents who have
children with eating issues. Only they can fully understand how
difficult the situation is on you and your child. Here are two good
forums made up of parents who know what you're going through: